CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 854 782.50 28943.25 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 577 591.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 797 794.50 29331.75 36.92
TCM-T1017TL-TARGETED CASE MANAGEMENT 983 3171.75 117327.00 36.99
TCON-TCON-TRANSITION CONFERENCE 131 132.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1582 5471.75 175602.00 32.09
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 21.50 1612.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 4.00 300.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 9.50 712.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.50 527.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 103 178.50 13387.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 84 135.50 10162.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 40 60.00 4500.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 83 148.50 8241.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 8.00 600.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 20 20.00 1000.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 225 605.00 41608.50 68.77
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 89 132.25 6612.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 19 32.50 1625.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 25 39.50 1975.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 35.00 1750.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 48 56.00 2800.00 50.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 11.00 275.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 231 1612.25 76452.50 47.42
INTR-INTR-INTERPRETER 19 31.75 1587.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 202 1177.75 78143.73 66.35
OCCT-97530HM-OT SESSION BY OT ASST 7 20.00 1086.40 54.32
PHY-97110-PT SESSION BY LICENSED PT 137 794.00 52536.15 66.17
PHY-97110HM-PT SESSION BY PT ASST 4 20.00 1086.40 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 420 2731.50 183724.37 67.26
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 731 149694 74537.00 0.50
Subtotal (Total Children Is Unduplicated) 958 156388 484191.55 3.10
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Total 162464.25 701402.05 4.32
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Number of Children (Unduplicated) With at Least One Service 1779
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Center 09
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 13129 157884.75 654879.60 654829.60
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
610 4579.50 46522.45 1643.63
Other 0 0.00 0.00 0.00
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Total 13739 162464.25 701402.05 656473.23